Patient Credit Card Authorization Form

{practiceName}

Account #: {accountNumber}

Practice Name

Account Number

ClarityX Contact (800) 380-9758

Patient Name*

First NameLast Name

Patient Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code

Patient Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Patient Email*

example@example.com

ClarityX Test*

Max Rx

Comprehensive Pharmacogenetics Panel

$250.00 QuantitySKU

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

I {patientName}, authorize Precision Sciences, Inc. dba ClarityX to charge my credit card above for agreed upon purchases. I authorize Precision Sciences, Inc, dba ClarityX to share my report with {practiceName}'s providers. I understand that once my order is shipped it cannot be modified or cancelled.

Patient Signature*

Date